• Plan Options
• Prescription Drug Coverage - Optional
• Formulary Requirements and Limits

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TTY/TDD should call
1-800-216-1307.
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Formulary Requirements and Limits

Some covered drugs may have additional requirements or limits on coverage and may include:

Prior Authorization (indicated on the Formulary by “PA”):

You may need prior authorization for drugs that are on the Formulary or drugs that are not on the Formulary and were approved for coverage through the Plan’s exceptions process. This means that your doctor must submit a Prior Authorization Request Form and receive approval from Care Assured before you fill your prescriptions. Without this approval, Care Assured may not cover the drug.

Quantity Limits (indicated on the Formulary by “QL”):

The Care Assured Value Plus Plan limits the amount of certain drugs the Plan will cover, in addition to a standard 30- or 90-day supply. This means that your doctor must submit a Quantity Limits Request Form and receive approval from Care Assured before you fill your prescriptions. Without this approval, Care Assured may not cover the drug.

Step Therapy (indicated on the Formulary by “ST”):

In some cases, Care Assured requires you to try certain drugs first to treat your medical condition before the Plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Care Assured may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Care Assured will then cover Drug B. Step Therapy Form.

You can find out if your drug has additional requirements or limits by checking the Care Assured Formulary.

Formulary Exceptions

You can ask the Plan to make an exception to a covered medication policy. There are two types of exceptions you can request:

1. You can ask us to cover your drug even if it is not on our formulary; or
2. You can ask us to waive coverage restrictions or limits on your drug.

Generally, Care Assured will only approve an exception if the alternative drugs included on the Plan’s formulary, the low-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

When submitting a Medication Exception Request Form, you must include a statement from your physician supporting your request. Generally, we must make our decision within 72 hours.